The student must approach reading differently than the classic “systematic” review of a particular disease entity. Patients rarely arrive to their healthcare provider with a clear diagnosis; hence, the student must become skilled in applying the textbook information to the clinical setting. Everyone retains more when the reading is performed with a purpose. Experience teaches that with reading, there are several crucial questions to consider thinking clinically. They are the following:
1. What is the most likely diagnosis?
2. What should be your next step?
3. What is the most likely mechanism for this process?
4. What are the risk factors for this condition?
5. What are the complications associated with this disease?
6. What is the best therapy?
Establishing the diagnosis was discussed in the previous part. This is a difficult task to give to the medical student; however, it is the basic problem that will confront clinicians for the rest of their careers. One way of attacking this problem is to develop standard “approaches” to common clinical problems. It is helpful to memorize the most common causes of various presentations, such as “the most common cause of mild respiratory distress in a term infant born by cesarean section is retained amniotic fluid (transient tachypnea of the newborn).”
The clinical scenario would entail something such as:
“A 3-hour-old infant is noted to have a mildly increased respiratory rate and slight subcostal retractions. The infant is term, large for gestation age, and was born by repeat cesarean section. The pregnancy was uncomplicated. What is the most likely diagnosis?”
With no other information to go on, the student would note that this baby has respiratory distress. Using the “most common cause” information, the student would guess transient tachypnea of the newborn. If, instead, the gestational age “term” is changed to “preterm at 30 weeks’ gestation,” a phrase can be added, such as:
“The mother did not receive prophylactic steroids prior to birth.”
Now, the student would use the “most common cause of respiratory distress in a pre-term child whose mother did not receive prenatal steroids” is surfactant deficiency (respiratory distress syndrome).
This question in many ways is even more difficult than the most likely diagnosis, because insufficient information may be available to make a diagnosis and the next step may be to pursue more diagnostic information. Another possibility is that the diagnosis is clear, but the subsequent step is the staging of the disease. Finally, the next step may be to treat. Hence, from clinical data, a judgment needs to be rendered regarding how far along one is on the road of:
Make diagnosis → Stage disease → Treatment based on the stage → Follow response
In particular, the student is accustomed to regurgitating the same information that someone has written about a particular disease but is not skilled at giving the next step. This talent is optimally learned at the bedside, in a supportive environment, with freedom to take educated guesses, and with constructive feedback. The student in assessing a child in the hospital should go through the following thinking process:
1. Based on the information I have, I believe that Cedric Johnson (a 3-month-old child with a positive respiratory syncytial virus nasal washing) has bronchiolitis.
2. I don’t believe that this is severe disease (such as significant oxygen requirement, severe retractions, or carbon dioxide retention on blood gas analysis). A chest radiograph shows no lobar consolidation (I believe this is important because a lobar consolidation would suggest a bacterial etiology).
3. Therefore, the treatment is supportive care with supplemental oxygen and intravenous fluids as needed.
4. I want to follow the treatment by assessing Cedric’s respiratory status (I will follow the oxygen saturation and degree of retractions), his temperature, and his ability to maintain his hydration orally without intravenous fluids. Also, if in the next few days Cedric does not get better or if he worsens, I think he will need a repeat chest radiograph to assess whether he has an evolving bacterial pneumonia.
In a similar patient, when the clinical presentation is not so clear, perhaps the best “next step” may be diagnostic in nature such as blood cultures to determine if bacteremia is present. This information is sometimes tested by the dictum, “the gold standard for the diagnosis and treatment of a bacterial infection is a culture.”
Sometimes the next step is therapeutic.
This question goes further than requiring the student to make the diagnosis; it also requires the student to understand the underlying mechanism for the process. For example, a clinical scenario may describe a 5-year-old child with Henoch-Schönlein purpura (HSP) who develops abdominal pain and heme-positive stools a week after diagnosis. The student first must diagnose the heme-positive stools associated with HSP, which occur in approximately 50% of patients. Then, the student must understand that the edema and damage to the vasculature of the gastrointestinal (GI) tract can cause bleeding along with colicky abdominal pain, sometimes progressing to intussusception. The mechanism of the pain and bleeding is, therefore, vasculitis causing enlarged mesenteric lymph nodes, bowel edema, and hemorrhage into the bowel. Answers that a student may speculate, but would not be as likely, include appendicitis, bacterial gastroenteritis, or volvulus.
The student is advised to learn the mechanisms for each disease process and not merely to memorize a constellation of symptoms. In other words, rather than trying to commit to memory the classic presentation of HSP (typical rash, abdominal pain, and arthritis), the student should also understand that vasculitis of the small vessels is the culprit. The vasculitis causes edema, mainly in the dependent areas, that precedes the palpable purpura. This vasculitis is responsible not only for edema in the joints (mainly in dependent areas such as the knees and ankles) causing the arthritis found in approximately two thirds of patients, but also damage to the vasculature of the GI tract leading to the intermittent, colicky abdominal pain that can manifest as heme-positive stools or even intussusception.
Understanding the risk factors helps to establish the diagnosis and interpret test results. For example, understanding the risk factor analysis may help to manage a 1-year-old child with anemia found on routine screening. If the child had no risk factors for lead poisoning or thalassemia, the practitioner may choose to treat with supplemental iron because the likelihood for more serious pathology is low. On the other hand, if the same 1-year-old child were a recent immigrant from an endemic area, lived in a older home with peeling paint, had a father who worked at a battery smelting plant, and ate meals from unglazed pottery, a practitioner should presumptively diagnose lead poisoning until proven otherwise. The physician may want to obtain a serum lead level and a complete blood count with differential (looking for basophilic stippling), and thoroughly evaluate the child for developmental delay. Thus, the number of risk factors helps to categorize the likelihood of a disease process.
A clinician must understand the complications of a disease so that the patient can be monitored. Sometimes, the student will have to make the diagnosis from clinical clues and then apply his or her knowledge of the sequelae of the pathologic process. For example, a child diagnosed with high fever, rash, lymphadenopathy, and oral and conjunctival changes is diagnosed with Kawasaki syndrome. Complications of this condition include arthritis, vasculitis of the medium-sized arteries, hydrops of the gallbladder, urethritis, and aseptic meningitis. Understanding the types of complications helps the clinician to assess the patient. For example, one life-threatening complication of Kawasaki syndrome is coronary artery aneurysm and thrombosis. The clinical presentation in the subacute phase is desquamation, thrombocytosis, and the development of coronary aneurysms with a high risk of sudden death. The appropriate therapy is intravenous immunoglobulin in the acute phase and high-dose aspirin as soon as possible after the diagnosis is made. Nonrecognition of the risk of coronary artery aneurysm and appropriate therapy for thrombosis can lead to the patient’s death. Students apply this information when they see on rounds a patient with Kawasaki syndrome and monitor for new murmurs, thrombocytosis, myocarditis, and development of coronary artery aneurysms. The clinician communicates to the team to watch the patient for any of these signs or symptoms so that appropriate therapy can be considered.
This is perhaps the most difficult question, not only because the clinician needs to reach the correct diagnosis, and assess the severity of the condition, but also because he or she must weigh the situation to reach the appropriate intervention. The student does not necessarily need to memorize exact dosages, but the medication, the route of delivery, and possible complications are important. It is important for the student to verbalize the diagnosis and the rationale for the therapy. A common error is for the student to “jump to a treatment,” almost like a random guess, and therefore be given a “right or wrong” feedback. In fact, the student’s guess may be correct but for the wrong reason; conversely, the answer may be a very reasonable one, with only one small error in thinking. It is crucial instead to give the steps so that feedback can be given for each step.
For example, what is the best therapy for a 15-year-old sexually active girl with severe, cystic acne? The incorrect manner of response is for the clinician to blurt out “Accutane.” Rather, the student should reason it as follows:
“Severe, cystic acne can be treated with a variety of modalities. Side effects of the medications must be considered in a sexually active teenager who is statistically at high risk for pregnancy. Accutane causes severe birth defects and is absolutely contraindicated in pregnancy. Therefore, the best treatment for this adolescent may be a combination of oral antibiotics and topical medications that present a much lower chance of devastating side effects.”
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Barness LA. Manual of Pediatric Physical Diagnosis. 7th ed. New York, NY: Lippincott Williams & Wilkins; 1998.
Barness LA. Pediatric history and physical examination. In: McMillan JA, DeAngelis CD, Feigin RD, eds. Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006: 39-51.
Blickman JG, Parker BR, Barnes PD. Pediatric Radiology: The Requisites. 3rd ed. Philadelphia, PA: Mosby Publishers; 2009.